Revisiting the relationship between beliefs and
mammography utilization.

Abstract:

Objective: Mammography rates have peaked and appear to be
decreasing, prompting the Centers for Disease Control and Prevention to
call for updated and expanded activities that promote breast cancer
screenings. The purpose of this study was to revisit the relationships
between perceived susceptibility, perceived benefits, perceived
barriers, and perceived access, and mammogram utilization for low-income
women 40 years and older.

Methods: A total of 99 women age 40 to 80 years (58% White, 41%
African-American, and 1% Asian) were recruited from seven urban health
centers.

Results: Slightly more that half the women (57%) surveyed reported
receiving a mammogram in the past year. Overall, women reported high
perceived susceptibility for breast cancer, positive benefits of
mammography, and low perceived emotional barriers for mammography.
Perceived access to mammography had a significant relationship to
mammogram utilization (p = .011). The odds of having a mammogram within
one year decreased by 28% for every unit increase in perceived access
barriers (OR = .716, 95% CI = .553 - .927). Cost, reported by 32% of the
women, was the most commonly reported perceived access barrier. Only 22%
of women reported receiving a physician recommendation for a mammogram.

Conclusions: Future breast cancer education campaigns should be
updated to communicate population-specific local screening resources and
encourage women to initiate a conversation with their health care
provider. Health care providers should also be targeted for future
mammography health education campaigns.

Government Agency: United States. National Center for Health
Statistics

Accession Number:

308741498

Full Text:

INTRODUCTION

Rates of mammography have increased significantly in the past two
decades. In 1987, approximately one-third (29%) of women 40 years and
older reported having a mammogram within the past two years (National
Center for Health Statistics, 2009). By 1999, 70.3% of women 40 years
and older reported having a mammogram within the past two years
(National Center for Health Statistics, 2009). Unfortunately,
mammography utilization peaked in 2000, at 70.4%, and has since
decreased. In 2005, the most recent reporting year, only 67% of women
age 40 years and older received a mammogram in the past two years
(National Center for Health Statistics, 2009).

In addition to the discouraging decreases in mammography
utilization, utilization remains lower for select populations. Lower
mammography rates are consistently reported for women of lower education
and income levels (Schuleler, Chu, & Smith-Bindman, 2008; National
Center for Health Statistics, 2009). In 2005, 58% of women over 40 years
of age who had less than a high school education received a mammogram.
However, 73% of women over 40 years of age who had some college or more
received a mammogram within the past two years (National Center for
Health Statistics, 2009). Likewise, 57% of women 40 to 64 years of age
with Medicaid received a mammogram compared with 75% of women 40 to 64
years of age with private insurance. The lowest level of mammography
utilization, by insurance type, was in uninsured women; 38% of uninsured
women 40 to 64 years of age received a mammogram within the past two
years (National Center for Health Statistics, 2009).

Tailored interventions appear to be more effective in increasing
mammography utilization. Intervention strategies are tailored to a woman
or a group of women by targeting specific behavioral antecedents that
may either inhibit or facilitate mammography participation. Behavioral
antecedents include demographic and physical traits, attitudes,
behavioral capabilities, and access to resources (National Cancer
Institute, 2007). For example, Latina women are more likely to report
safety concerns as a barrier for breast screenings (Schueler, Chu &
Smith-Bindman, 2008). However, the ability to speak English is a strong
predictor of mammography utilization in Asian American women (Liang,
Wang, Chen, Feng, Yi, & Mandelblatt, 2009; Wu, Bancroft &
Guthrie, 2005). Tailored client-oriented activities that have produced
increases in mammography-related outcomes include client reminders,
small media, one-on-one education, and reducing out-of-pocket expenses
(Guide to Community Preventive Services, 2009).

Given the declining rates of mammography utilization, the Centers
for Disease Control and Prevention (CDC) has called for an expansion of
activities that promote breast cancer awareness and screening (2007). A
preliminary step in updating and expanding such awareness and screening
campaigns is to reassess factors that improve or hinder mammography
utilization. Current information about the factors for specific
populations will allow for the development of tailored breast cancer
awareness and screening programs. The purpose of this study was to
revisit the relationship of perceived susceptibility, perceived
benefits, perceived barriers, and perceived access to mammogram
utilization in low-income women. Low-income women 40 years and older who
attended local health centers were purposefully recruited for this
study. Recruiting women from a community health center controlled for
physician access, a documented predictor of mammography utilization
(Schueler et al., 2008; Smith & Hayes, 1992; Valdini & Cargill,
1997). The focus of the study variables was on the attitudinal factors
that could be targeted by health education campaigns. Physician and
facility access are potential targets for health care policy
interventions.

The target population was low-income women 40 years and older who
attended local community health centers in one southwest Ohio city.
Seven centers, all located within the city limits, were used to recruit
subjects. The health centers reported that the maximum income of
individuals or families receiving care was 300% of the federal poverty
level (FPL). This level was calculated to be less than $29,400 for one
person, and less than $60,000 for a family of four. The principal
investigator approached women in the waiting room of the participating
local health centers and explained the purpose of the study. If the
woman agreed to participate in the study, she was given the
questionnaire. All women returned the anonymous questionnaire to the
principal investigator. The data were collected during a 60-day period
in the summer of 2007. The university's Institutional Review Board
for Human Subjects approved the methodological techniques of this study.

The rule of ten was used to estimate sample size in both designing
the study and in fitting the logistic regression model. The rule of ten
states that the minimum number of subjects equals 10 divided by the
smaller proportion of the two outcome categories multiplied by the
number of independent variables (van Belle, 2002). The original design
included six variables: the four attitudinal variables, education level,
and family history. After the descriptive analysis of the data, race and
employment status were explored. Half the women were expected to have
reported a mammography within the past year; thus, approximately 120
subjects were needed in the sample to insure generalizability of the
results. After descriptive analysis and using the smallest proportion of
the outcome variable (0.43), up to four variables could be included in
the final logistic regression model.

INSTRUMENTATION AND DATA COLLECTION

There were four attitudinal predictor variables of interest in this
cross-sectional study: perceived susceptibility, perceived benefits,
perceived emotional barriers, and perceived access. All variables were
measured via a self-administered questionnaire. The questionnaire was
developed from Champion's validated and published questionnaire
(Champion, 1999). The perceived benefits scale was edited from
Champion's five item scale to three items. The perceived barriers
scale was edited from Champion's 11-item scale; the new scale
focused on emotional barriers. The perceived access items were edited
from Valdini and Cargill (1997). The attitudinal variable items used a
4-point Likert scale of strongly disagree, disagree, agree, and strongly
agree (Table 1). The mammogram utilization item asked the number of
screening mammograms in the past five years. The dependent variable was
recoded to a binary variable: a mammogram within the last year or no
mammogram within the last year.

Four demographic variables were measured as possible confounders:
educational status, family history of breast cancer, race, and
employment status (see Table 2). After descriptive analysis, three of
the variables were recoded. Educational status was coded as high school
graduate or not a high school graduate. Race was recoded as white,
African American or other. Employment was recoded as currently employed
or unemployed.

Face validity for the questionnaire was determined through a review
by a community cancer prevention nurse specialist and an expert in
health behavior theory. The questionnaire was field tested with three
women, over age 40, who were seeking services at a local community
center that provided food and health services to low-income individuals
and families. The women completed two versions of the same
questionnaire. All women preferred the same format.

DATA ANALYSIS

Descriptive statistics as well as measures of association were
calculated for all study variables. Variables that had at least a modest
correlation, p < 0.15, with mammography utilization were considered
for inclusion in the preliminary logistic regression model (Hosmer &
Lemeshow, 2000). Rank biserial correlation coefficients were calculated
for the ordinal variables, and phi coefficients were calculated for the
binary variables (Khamis, 2008). Removal of variables in the final model
was done using a backward stepwise likelihood ratio test based on
significance (p < .05). Collinearity was analyzed via the correlation
matrix of the study variables. The Hosmer and Lemeshow's Test was
then analyzed for model goodness of fit. Analysis was performed using
SAS Statistics 9.2.

RESULTS

SUBJECTS

Of the 121 questionnaires collected, 99 questionnaires were used in
the analyses. Five women were excluded because they were under age 40
and 17 additional questionnaires were incomplete. The women in the
remaining sample were white (58%), African-American (41%), and Asian
(1%). Most of the women had graduated high school and/or gone to college
(85%). One third of the population (28%) reported being married. The
remaining women reported various forms of singleness: divorced, single,
separated and or widowed. Slightly more than half of the women (52%)
reported a family history of breast cancer (Table 2).

MAMMOGRAPHY UTILIZATION AND BELIEFS

The majority (57%) of the 99 women surveyed reported having had a
mammogram in the last year (see Table 2). One-third of the women
reported having had a mammogram in the past few years, but less than
annually. Only 7% of the women reported never having had a mammogram.

Women reported high perceived susceptibility for breast cancer,
5.79 on a 9-point scale (see Table 1). Perceived benefits of mammograms
were also high, 7.06 out of 9. Women reported low perceived emotional
barriers (3.00 on a 9-point scale) and low perceived access to getting a
mammogram (2.98 on a 9-point scale).

LOGISTIC REGRESSION

Two variables were included in the preliminary logistic regression
model: perceived emotional barriers and perceived access. These
variables had at least moderate relationships with mammography
utilization (See Table 3). A relationship with mammography utilization
was also confirmed by a Wilcoxon two-sample test that compares the
median value of the variable for the two levels of mammography
utilization. The median values of perceived barriers (p = 0.010) and
perceived access (p = 0.006) were statistically significantly higher for
mammography utilization within one year.

In the final model, perceived emotional barriers was not a
significant predictor of mammography utilization (p = 0.147). Perceived
access had a significant relationship to mammogram utilization (p =
.011). The odds of having a mammogram within one year decreased by 28%
for every unit increase in perceived access barriers, (OR = .716, 95% CI
= .553 - .927). The model had acceptable goodness of fit ([chi square]
(8) = 10.873, p = .209). There was not collinearity in perceived access
and perceived emotional barrier, r = .303, nor was there a significant
interaction of the two variables (p = 0.087).

DISCUSSION

The Healthy People 2010 goal for breast health is that at least 70%
of women 40 years and older will have had a mammogram in the past two
years. In the present investigation, 57% of our sample reported having
had a mammogram in the past year, and 69% reported a mammogram in the
past two years. By comparison, US data for 2005 indicate 48.5% of women
age 40 years and over living below 100% federal poverty reported having
a mammogram within the past two years. As income level increases, so do
the reported levels of mammography. About three-quarters of women age 40
years and over with income at least 200% of poverty level reported
having a mammogram within the past two years. Women in poverty show a
decrease in reported mammography utilization since 1999 (National Center
for Health Statistics, 2009).

The present study also found both perceived susceptibility for
breast cancer and perceived benefits for mammography were very high:
5.79 on a 9-point scale and 7.06 on 9-point scale. The high level of
susceptibility to breast cancer is noteworthy. While not specifically
evaluated in this study, one might hypothesize that the high perceived
risk levels may be attributed to previous breast cancer awareness
campaigns, as well as heightened personal exposure to breast cancer.
Breast cancer awareness campaigns have grown exponentially in the past
two and a half decades. The magnitude of these awareness campaigns is
demonstrated via the growth of the Susan G. Komen breast cancer
awareness walks, Race for the Cure[TM]. The first Race for the Cure[TM]
was held in 1983 with 800 walkers. In 2008, over 1.5 million people
participated in over 100 awareness walks (Susan G. Komen Race for the
Cure Foundation, 2008). Furthermore, when these campaigns were emerging,
a woman's lifetime probability of being diagnosed with breast
cancer was 1 in 10, whereas the current probability of being diagnosed
with breast cancer is 1 in 8 (National Cancer Institute, 2006). Thus,
women are more likely to have a family history or friend who was
diagnosed with breast cancer. In the present study, half the women
reported a family history of this disease.

Perceived access was a significant predictor of mammogram
utilization (p < 0.05). The higher the reported perceived access
barriers, the less likely a woman was to have had a mammogram in the
past year. Descriptively, one-third of the women in our investigation
reported cost as an access issue. Access factors, particularly cost,
have consistently been reported as a mammography utilization barrier by
other researchers. In two separate literature reviews, from years 1988
to 2004 and from years 1990 to 1999, both researchers concluded cost as
a strong predictor of mammogram frequency (Schueler et al. 2008;
Yarbrough & Braden, 2000).

The cost of a mammogram has been an intervention target for the
past 25 years. The Breast and Cervical Cancer Early Detection Program
was established by the Centers for Disease Control and Prevention in
1991 to provide breast and cervical cancer screenings to low-income,
uninsured women (U.S. Department of Health and Human Services, 2005).
Between the years of 2002-2006, 1.77 million mammograms were funded. In
Ohio, during the same time period, 39,702 mammograms were provided (CDC,
2008). Within this study, all seven health centers recruited for this
study had programs to provide vouchers for screening and diagnostic
mammograms.

The perception of cost and access appears to be emerging as a
current mediating barrier. In this study, all seven health centers
recruited for this study had programs to provide vouchers for screening
and diagnostic mammograms. McAlearney et al. (2005) also found that
women erroneously reported cost of the mammogram as a barrier. In their
large randomized controlled study evaluating the impact of a health
education intervention to improve mammography in rural low-income women,
53% of the women who had not received a mammogram in the past two years
stated cost as the barrier; 40% of those women had an erroneous
perception of their insurance coverage. In a follow-up analysis, race,
income, and education level were not related to cost as a barrier
(2007).

Surprisingly, only 22% of the women surveyed reported that they had
received a physician recommendation to get a mammogram. We found this
percentage much lower than expected, given that the women were recruited
from local community health centers. For women of lower SES, a
physician's recommendation is considered to be an important
facilitator of mammography behavior (Fulton et al, 1991; McDonald et al.
1999). Fifteen years earlier, Fulton reported that less than half of the
women reported receiving a recommendation for a mammography and that the
provider's recommendation had the greatest independent effect on
predicting screening status, compared with other health belief model
constructs (1991). More recently, after reviewing 221 mammography
utilization factor studies, Schueler concluded that a provider's
recommendation was "highly predictive of not obtaining mammography
(2008, p. 1477)".

Race, family history, employment, and education level were not
significant predictors, nor confounders, with mammography utilization.
Due to the sample characteristics, race was narrowly evaluated as
African American versus White. Nationally, current mammography
utilization in these two groups appears to be similar; however,
differences are consistently noted for Latina and Asian Americans
(National Center for Health Statistics, 2009). We were unable to test
for these differences. Family history and education level findings
should be interpreted with caution. Previous findings have consistently,
and over time, found education level (completed high school verses less
than high school) as a predictor of mammography utilization (Fulton et
al., 1991; Raham, Dignan, & Shelton, 2005; Schueler et al. 2008).
Previous findings also suggest that family history may have an
interactive effect with age, and age was not a variable of interest in
this study (Raham, Dignan, & Shelton, 2005; Schueler et al. 2008).

The convenience sample, self-selection for inclusion in the study,
the use of self-report data, and the method in which select variables
were measured are notable limitations of this study. The convenience
sample was recruited from women attending local health centers. Thus,
participants had access to a health care provider, but whether the woman
had a regular physician or care provider was not assessed. Furthermore,
women attending a local health center, and who agreed to complete the
questionnaire, may have had more positive beliefs about health and
health behaviors than low-income women recruited through other means.
Women self-reported mammography utilization and time since last
mammogram, and thus, these values may have been over-reported. Women
also reported family history of breast cancer and thus, this method
captured the perception of family history, not actual epidemiological
risk. Low-income status was assumed by attendance at the local health
center. Economic status operationalized by actual income level, type of
assistance, or other measures might change the findings, particularly
for the relationship of cofounders, education level and employment
status.

IMPLICATIONS FOR HEALTH EDUCATION PRACTICE

Modern breast cancer campaigns originated in the 1970's and
focused on susceptibility of breast cancer and age-related screening
guidelines (Lerner, 2001). Results from this study appear to support the
need to update efforts to improve mammography utilization among
low-income women who attend health centers. Women in this study
perceived high levels of risk for breast cancer, high levels of reported
benefits, and low levels of emotional barriers. Future breast cancer
awareness and education campaigns should target women's perceived
access to screening services. Campaigns should communicate the
availability of local resources for screening mammograms. Given the low
levels of reported health care provider recommendations, campaigns may
also encourage women to initiate the conversation with their health care
provider.

Health care providers should also be aggressively targeted for
future health education programs. Practitioners should talk to
low-income women about screening mammograms, as research indicates that
women are receptive to this message. Surprisingly, only a fifth of the
women in this study reported receiving a physician recommendation for a
screening mammogram. The patient/provider conversation should focus not
on issues of risk and fear, but provide women of low-income status
specific information on access to local resources.

REFERENCES

Centers for Disease Control and Prevention (2008). National Breast
Cancer & Cervical Cancer Early Detection Program Screening Program
Summaries. Retrieved April 30, 2008 from http://www.cdc.gov/
cancer/NBCCEDP/data/summaries/national_aggregate.htm

Centers for Disease Control and Prevention (2007). Self-reported
use of mammograms--United States, 2003-2005. Morbidity and Mortality
Weekly Review, 56(03), 49-51.

National Cancer Institute (2006). Fact sheet: Probability of breast
cancer in American women. Retrieved on May 8, 2008 from
http://www.cancer.gov/cancertopics/factsheet/Detection/probability-breast-cancer.

National Center for Health Statistics (2009). Health United States,
2008. With Chartbook. Retrieved November 1, 2008 from
http://www.cdc.gov/nchs/data/hus/hus08.pdf